Allergic Rhinitis

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Rhinorrhea

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Allergic rhinitis (AR) is a systemic illness characterized by persistent nasal symptoms (aka “Hay Fever” or “Grass Fever”).

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Seasonal Allergic Rhinitis

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(SAR) occurs periodically and predictably with specific seasons

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Perennial allergic rhinitis

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(PAR) occurs year-round independent of the seasons

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Episodic allergic rhinitis

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occurs sporadically in response to inhaled aeroallergens that are not usually in the patient’s environment (e.g., after being exposed to a horse at a petting zoo)

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Rhinitis medicamentosa (or RM)

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Condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) that work by constricting blood vessels in the lining of the nose.

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Lacrimation

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the production, secretion, and shedding of tears

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Hyperemia

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Common symptom of pink eye

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Conjunctival Injection

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Bloodshot eyes

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Priming (a.ka. sensitization)

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The nasal mucosa is more sensitive to environmental allergens with continued exposure.

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Nasal hyperresponsiveness

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The nasal mucosa reacts to non-IgE-mediated stimuli (smoke, perfume, strong odors). The irritant receptors becomes more sensitive and there is altered regulation/degeneration of mast cell mediators.

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Symptoms of Mild Allergic Rhinitis


(Wallace et al J Allergy Clin Immunol 2008)

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Symptoms present but not troublesome (no sleep disturbance, no impairment of daily activities)

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Symptoms of More Severe Rhinitis


(Wallace et al J Allergy Clin Immunol 2008)

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More symptoms and/or impaired quality of life

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Controlled Allergic Rhinitis

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No interference with activities; < 2 days per week
sneezing, itching, congestion, eye symptoms

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Fair Controlled Allergic Rhinitis

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Mild interference with activities; 2-6 days per week sneezing, itching, congestion, eye symptoms

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Not Controlled Allergic Rhinitis

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Severe interference with activities; daily sneezing, itching, congestion, eye symptoms

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Histamine - Mediator and Symptoms

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Tickling
Itching
Nose Rubbing
Allergic salute
Sneezing
Nasal congestion
Stuffy nose
Mouth breathing
Snoring
Runny nose
Postnasal drip
Throat clearing

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Prostaglandins - Mediator and Symptoms

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Tickling
Itching
Nose Rubbing
Allergic salute

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LEUKOTRIENES - Mediator and Symptoms

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Sneezing
Nasal congestion
Stuffy nose
Mouth breathing
Snoring
Runny nose
Postnasal drip
Throat clearing

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BRADYKININ - Mediator and Symptoms

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Nasal congestion
Stuffy nose
Mouth breathing
Snoring

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Platelet activating factor - Mediator and Symptoms

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Nasal congestion
Stuffy nose
Mouth breathing
Snoring

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Early phase response

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The immediate response to inhaled allergen. Caused by preformed and newly formed mast cell mediators (histamine, prostaglandins, leukotrienes and other).

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Late phase response

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Occurs 4-8 hours after exposure to inhaled allergen. Caused by de novo inflammatory mediator synthesis (cytokines, chemoattractants, etc).

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Tolerance

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Decreased drug effect with continued use. Probably not real – usually related to noncompliance or worsening of disease rather than loss of drug effect.

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Typical seasonal allergens

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airborne pollens (trees, grasses, weeds, and some insect pollinated plants) [Philadelphia pattern: trees in early spring, grasses in spring, weeds in late summer, molds throughout the growing season.

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Typical perennial allergens:

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house dust mites, molds, animal dander, cockroaches, wool, latex, resins, chemicals, organic dusts, biologic enzymes

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Pollen/Mold Spore Counts LOW

(# grains or spores per m3 per 24 hours)

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Only the most sensitive.

Weeds: 0-10
Grasses: 0-5
Trees: 0-15
Molds: 0-900

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Pollen/Mold Spore Counts Moderate

(# grains or spores per m3 per 24 hours)

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Many Sensitive people.

Weeds: 10-50
Grasses: 5-20
Trees: 15-90
Molds: 900-2500

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Pollen/Mold Spore Counts High

(# grains or spores per m3 per 24 hours)

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Most Sensitive people

Weeds: 50-500
Grasses: 20-200
Trees: 90-1500
Molds: 2500-25k

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Pollen/Mold Spore Counts Very High

(# grains or spores per m3 per 24 hours)

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Everyone with any sensitivity

Weeds: 50-500
Grasses: 20-200
Trees: 90-1500
Molds: 2500-25k

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Determine if Self-care is appropriate

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Self-care is appropriate if the following conditions are met:

• The patient has signs and symptoms consistent with allergic rhinitis.
• The patient has no underlying disease or condition that negates the use of OTC meds.
• The patient does not have a complication of allergic rhinitis.

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Symptoms associated with Allergic Rhinitis

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• stuffed-up nose (78%)
• repeated sneezing (51%)
• runny nose (62%)
• headache (51%)
• postnasal drip (61%)
• itchy palate/throat (46%)
• red itching eyes (53%)
• facial pain (43%)
• watering eyes (51%)
• ear pain (30%)

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Physical Assessment assoicated with Allergic Rhinitis

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• “allergic shiners”
• “allergic crease”
• “allergic salute”
• pale/blue swollen nasal mucosa
• clear and watery nasal secretions
• watery eyes
• scleral and conjunctival injection
• periorbital edema

Children: sniff, snort, clear throat; chronic gaping mouth, halitosis, cough, dark circles under eyes, rub eyes, rub nose, poor appetite, falling behind at school

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Triage Questions to ask before recommending drug Therapy

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1. What are your symptoms?
2. Are the symptoms present year-round or only during certain times of the year?
3. What factors make your symptoms worse?
4. Are your symptoms better or worse at home or at work/school?
5. Does anyone in the family have a history of allergies?
6. Do you have a fever, sore throat, cough, vomiting, or diarrhea?
7. What OTC and Rx medications are you currently taking?
8. What OTC and Rx medications have you taken in the past?
9. Are you allergic to any medications?

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State the three steps involved in the management of allergic rhinitis.

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Step 1. Environmental Control
Step 2. Medications
Step 3. Allergen Immunotherapy

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Environmental Control (Avoidance)

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The house dust mite (Dermatophagoides farinae and D. pteronyussinus) is the most common cause of PAR. Mites thrive anywhere dust collects (carpets, upholstery, bedding, stuffed animals, book shelves, etc.); feed on human skin scales; reproduce best under typical household conditions (65-70F and > 50% humidity). The allergen is a glycoprotein that coats the mite feces.

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Environmental Control - Outdoor pollens and molds

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Pollens: Keep house windows, car windows, and outside vents closed. Grass pollens: avoid freshly mowed areas (don’t mow the grass). Stay inside on sunny windy days.
Molds: avoid rotting vegetation (compost heaps, mulch).

Consider using a face mask if unavoidable exposures.

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Environmental Control - Indoor molds

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Vent kitchen; dehumidify, fix wet basements.

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Environmental Control - Animal dander

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Remove pet from household (at least keep pet out of bedroom); bathe cats weekly or biweekly (unknown efficacy); HEPA filtration may remove cat allergens.

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Environmental Control - Cockroaches

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Use pesticides (may have to relocate if multifamily building).

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Environmental Control - Pollutants/Irritants

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Avoid wood burning stoves and fireplaces; vent other stoves and heaters; avoid perfumes, cleaning agents, and sprays that trigger symptoms.

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Environmental Control - House dust mite*

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Reduce indoor humidity to < 50%. Remove carpets. Remove dust collectors from at least the bedroom (stuffed toys, upholstered furniture, books). Encase pillows, mattresses and box springs in mite-impermeable material. Clean bedding in hot water (130F) weekly. Vacuum with high efficiency particulate filter (HEPA) vacuum cleaners; consider HEPA filters in HVAC systems. Consider frequent acaracide application

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Nondrug Therapy

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1. Nasal lavage with nonprescription saline solutions (e.g., Ocean) or home-made saline solutions (e.g., mix 1 tsp noniodized salt, 1 tsp baking soda, 500 ml distilled or boiled water)
• Of modest benefit
• Proposed MOA include improved mucous clearance, enhanced ciliary beat frequency, and removal of antigens, biofilm, and inflammatory mediators
• Side effects include burning, irritation, nausea

2. Inhale warm mist through nose for 10-15 minutes 2-4 times/day (eg, steamy showers).
• Of modest benefit

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Allergen Immunotherapy Description I

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A series of subcutaneous injections using patient-specific antigens. Weekly injections with increasingly concentrated antigens. Maintenance dose reached in 4-8 months then continued for 3-5 years. 80% of patients have significant relief; 60% remain asymptomatic after treatment course completed.

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Allergen Immunotherapy Description II

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1. Mechanism – not known

2. Side effects – anaphylactic reactions, local side effects

3. Indication – for patients who are symptomatic after natural exposure to allergens and who have IgE antibodies to the relevant allergens; for patients with more severe disease, those who cannot be controlled with medications or with co-morbidities

4. Contraindications
• Severe, uncontrolled asthma
• Significant or unstable cardiovascular disease
• Concurrent beta-adrenergic blocking drugs

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Prophylaxis before exposure

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Nasal mast cell stabilizer, oral antihistamine or nasal antihistamine prior to exposure and then PRN for symptom-relief

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Episodic Allergic Rhinitis

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Symptom-targeted therapy (one or more medications depending on symptoms and severity)

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Mild Allergic Rhinitis

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Symptom-targeted therapy (one medication)

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Moderate Allergic Rhinitis

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Change to a different medication or add a second medication

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Moderate to Severe Allergic Rhinitis

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Add a second medication or change one or more medications

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Severe Allergic Rhinitis

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Add a short course or oral corticosteroids

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Antihistamines - Symptom Targeted Therapy

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-Sneezing
-Rhinorrhea
-Itching

2nd generation antihistamines preferred

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Decongestants - Symptom Targeted Therapy

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Nasal Congestion

Oral decongestants preferred

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Anticholinergics - Symptoms Targeted Therapy

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Rhinorrhea

Prescription only; $$$

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Corticosteroids - Symptoms Targeted Therapy

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-Sneezing
-Rhinorrhea
-Nasal Congestion
-Itching

Intranasal steroids preferred; the most effective anti-inflammatory drug

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Leukotriene Receptor Antagonists - Symptoms Targeted Therapy

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-Sneezing
-Rhinorrhea
-Nasal Congestion
-Itching

Less effective than CS

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Cromones - Symptoms Targeted Therapy

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-Sneezing
-Rhinorrhea
-Nasal Congestion
-Itching

Less effective than LTRA

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Intranasal steroids - Place In Therapy

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1st line therapy for all forms and severity of disease; best if started prior to onset of seasonal symptoms and used daily though may provide some relief when used PRN

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Intranasal antihistamines - Place In Therapy

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1st line therapy for all forms and severity of disease but less effective than intranasal corticosteroids; are absorbed so may relieve non-nasal symptoms

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Oral antihistamines - Place in Therapy

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Second generation antihistamines recommended; may be effective as single drug therapy for mild disease; combined with intranasal steroids or decongestant for moderate-severe disease;

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Systemic decongestants

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Add-on therapy to intranasal steroids for patients with moderate-to-severe nasal congestion

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Intranasal decongestants - Place in Therapy

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Use limited to 3 days due to risk of rhinitis medicamentosa

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Oral leukotriene receptor antagonists - Place in Therapy

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Less effective than INS; generally limited to treating mild disease; when combined with an antihistamine may replace intranasal corticosteroids

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Intranasal mast cell stabilizers - Place in Therapy

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Less effective and less convenient than INS; takes up to two weeks to see full benefit (prevents, doesn’t alleviate symptoms); need patent nasal passageways (may need antihistamine and/or decongestant pretreatment); generally limited to treating mild disease and for prophylaxis

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Intranasal anticholinergics - Place in Therapy

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Only controls rhinorrhea

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Oral corticosteroids - Place in Therapy

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Rarely used; limited to short courses (5-7 days) in severe disease

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Managing Allergic Rhinitis During Pregnancy

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• First-line therapy: intranasal cromolyn (safe but inconvenient and not very effective)

• Second-line therapy: antihistamines (chlorpheniramine and tripelennamine have a good safety record but are sedating; loratadine is the only Category B nonsedating antihistamine; cetirizine is Category B). Can use intranasal corticorticosteroid instead of oral antihistamine (most experience with beclomethasone; budesonide has a good safety record).

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Spray Bottles - Advantages and Disadvantages of Major Nasal Drug Delivery Systems

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Adv:
Simple to use.
Rapid onset of action.
Inexpensive.
Covers a large surface area.

Disadv:
Imprecise dosing.
High risk for contamination.
Tips prone to clogging.
Hard to give to a child.

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Metered-Dose Spray Pumps - Advantages and Disadvantages of Major Nasal Drug Delivery Systems

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Adv: Precise dosing.
Disadv: Expensive

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Droppers - Advantages and Disadvantages of Major Nasal Drug Delivery Systems

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Adv: Easy to give to a child.
Disadv: Awkward self-administration.
High risk for contamination.
Covers a small surface area.

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Nasal Inhalers - Advantages and Disadvantages of Major Nasal Drug Delivery Systems

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Adv: Small, unobtrusive.
Disadv: Rapid evaporation.
Need adequate inspiratory flow rate to deposit drug.

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General counseling - Allergic Rhinitis

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1. Wash hands before using.
2. Discard if solution is discolored or if suspect contamination.
3. Shake the container if appropriate (product-specific).
4. Remove cap before use; replace after use.
5. Do not touch the tip.
6. Rinse tip with hot water but don’t let water get into bottle.

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Ocular - Adminstration Technique

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1. Tilt head back slightly.
2. With first finger, pull lower lid down and away from eye (forms a pocket).
3. Look up to make sure dropper tip is directly above the eye.
4. Look away and release a drop.
5. Release eyelid.
6. Close eye for 1-2 minutes and press the inner corner of the eye with first finger.
7. Do not rub eye.
8. Wait several minutes between doses.

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Intranasal Spray - Adminstration Technique

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1. Gently insert bottle tip into one nostril.
2. Keep head upright.
3. Sniff deeply while squeezing the bottle.
4. Repeat with the other nostril.

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Metered-Dose - Adminstration Technique

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1. Prime the pump before using the first time (depress the pump several times with the nozzle
pointed away from the face).
2. Hold the bottle with the nozzle between the first two fingers with the thumb on the bottom of
the bottle.
3. Gently insert the tip into one nostril.
4. Keep the head upright.
5. Sniff deeply while depressing the pump once.
6. Repeat with the other nostril.

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Dropper - Adminstration Technique

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1. Squeeze dropper bulb to withdraw medication from the bottle.
2. Tilt head back if standing or lay on bed with head tilted back and over the side of bed.
3. Place the drops into each nostril.
4. Gently tilt the head from side to side.
5. Rinse the dropper with hot water; let air dry.

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Nasal Inhaler - Adminstration Technique

Back 76

1. Warm the inhaler in hand immediately before use.
2. Gently insert inhaler tip into one nostril.
3. Sniff deeply while inhaling.
4. Wipe the inhaler clean after each use.
5. Make sure the cap is on tight.
6. Discard the inhaler after 2-3 months even if still smells medicinal.